Reviewing a surgeon you have never met: the evidence pack

01

What you are actually reviewing

Be precise about the claim you are making, because it is narrower than people assume.

You are not reviewing a surgeon. You are reviewing a record of decisions and a record of outcomes, and inferring from both. Judgement in the moment, tissue handling, the decision to stop, the thing a good operator notices at minute forty: none of that reaches you. What reaches you is what was written down, photographed, prescribed and followed up.

There is a body of work on closing that gap directly. A 2023 systematic review in Surgical Endoscopy identified forty one video based tools for assessing technical skill in laparoscopic procedures across nine specialties, and of the twelve studies that tested those tools against real patient outcomes, eleven found a positive relationship between the quality rating and the clinical result. That is a genuine finding and it matters. It also does not help you on Monday, because routine practice in most settings produces no usable footage at all.

So the record is your evidence. Which makes the specification of the record the actual quality intervention.

02

The six file pack

This is the checklist I would put in front of any network reviewing work it does not directly supervise. Six files per case, named and numbered the same way every time.

**One, the consent and decision record.** What the patient was told, what alternatives were discussed, what was declined and why. This is where you find out whether the operation should have happened.

**Two, the pre procedure assessment.** Baseline measurements, relevant history, medications, the plan as written before anyone scrubbed. Without a documented baseline, the outcome cannot be assessed at all, only admired.

**Three, the operative note.** Date and time, elective or emergency, the named surgeon and the named assistant, the anaesthetist, the procedure performed, findings, complications, and post operative instructions.

**Four, the photographs.** Under a protocol, which I come to below.

**Five, the materials and drug record.** What was used, how much, what was given, batch numbers where they exist.

**Six, the follow up log.** Scheduled contacts, who made them, what the patient reported, and what was done about it.

Six files. Fixed names. Uploaded within seventy two hours of the case, by the person who did the work, not by an administrator reconstructing it later.

On the operative note, the evidence for structure is unusually clear. A 2023 closed loop audit in Cureus scored general surgical operation notes against the Royal College of Surgeons of England's Good Surgical Practice standard. Before the unit introduced a structured template, complications were documented in 21.5 percent of notes and the type of operation in 45.6 percent. After the template, both figures cleared 92 percent. Nobody became a better surgeon in the interval. The form changed.

03

Photographs are a protocol or they are decoration

Every network I have seen collects images. Almost none collect comparable ones. Different phone, different distance, different light, patient facing a different way, and a reviewer who cannot tell improvement from a better camera angle.

A 2014 PLoS ONE paper on collecting images in remote communities is the useful reference here, because it deals with exactly your problem: untrained photographers, no studio, high staff turnover. The authors set out to "standardise the equipment, camera settings, participant positioning and photography technique", and 96.8 percent of the images they gathered passed quality control. Two reviewers, blinded to treatment allocation and to the order of the images, agreed on success or failure in 86 percent of cases, with a kappa of 0.4.

That kappa is fair, not strong, and I think it is the honest ceiling on what image review gives you. It is enough to spot the outlier and the trend. It is not enough to grade a competent operator against another competent operator, and reviews that claim otherwise are selling something.

Write the protocol on one page. Fixed angles, fixed distance, a scale in frame, the same lighting position, the same patient orientation, and the same set at every timepoint. Then put it on the wall of the room where photographs are taken.

04

What the gaps tell you

Here is the part most quality systems get backwards. They treat a missing document as an obstacle to the review.

If the operative note does not name who performed the procedure, that is a finding. If there is no baseline, the outcome claim is unsupported and should be recorded as unsupported. If follow up contacts exist as a WhatsApp thread and nothing else, the practice has no way to demonstrate aftercare to anyone who asks, including a regulator or a lawyer.

Score completeness separately from quality, and report both. A practice at ninety percent completeness with mixed outcomes is a practice you can help. A practice at forty percent completeness with excellent reported outcomes is a practice you know nothing about, and saying so plainly is more useful than a generous score.

Ask once, set a date, and if the file does not arrive, close the case as incomplete. Do not chase for three months. Chasing teaches people that the deadline is negotiable, and the deadline is the whole mechanism.

A missing record is not missing information. It is information.

05

What this gets you, and what it does not

Separate the two lists before you start, because confusing them is how these programmes lose credibility.

Not yours: whether a doctor two thousand kilometres away exercises good judgement at the moment it counts. Whether a difficult case was salvageable. Whether the patient followed instructions after they went home. You will never observe any of it, and a review that implies you did will be dismissed by the clinicians it is meant to influence, correctly.

Yours: what evidence must exist, what shape it arrives in, how fast, who signs it, what happens when it is missing, and what you do with the pattern once you can see it across fifty cases instead of one. That is a real set of controls and it is entirely within your gift.